Management of Failed Proximal Biceps Surgery: Clinical Outcomes After Revision to Subpectoral Biceps Tenodesis.

BACKGROUND: The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics. PURPOSE: To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients undergoing revision biceps management by the senior surgeon between 2006 and 2016 and with a minimum 24-month follow-up were retrospectively identified. Patients being treated with concomitant rotator cuff repair or capsular release were excluded. Patient characteristic variables were recorded. Patient-reported outcomes including the functional score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons were obtained, and range of motion, strength, and complications were quantified. RESULTS: In total, 25 patients with revision biceps tenodesis were identified at a mean follow-up of 76.5 ± 31.5 months. The average age was 44.4 ± 14.3 years, and the surgical indications included failure of index suprapectoral biceps tenodesis (56%), subpectoral biceps tenodesis (36%), and patient dissatisfaction after tenotomy (8%). There was a significant improvement in the VAS score (P < .001), SANE (P = .001), SST (P = .035), functional score (P < .001), and forward elevation (P = .028), whereas postoperative strength (P = .440), abduction (P = .100), and external rotation (P = .745) improvement failed to achieve statistical significance after revision surgery. There was no difference in postoperative outcome measures between modes of failures, concomitant procedures, and sex. Twenty-two (88%) patients reported high satisfaction and stated they would have this revision surgery again. The overall complication rate was 48%, with half of these reporting pain of >3 on a scale of 10 and 4% of patients requiring additional surgeries. CONCLUSION: The current study demonstrates high patient satisfaction (88%) and significant improvement in functional outcomes with revision biceps tenodesis, a mini-open subpectoral technique, after previous failed tenodesis or tenotomy. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Patients should be counseled on the high complication rate (48%), with persistent pain being the most common complaint.

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers' compensation patients.

BACKGROUND: Outcomes of shoulder surgery in workers' compensation (WC) patients have generally been inferior to those in non-WC patients. The purpose of this study was to compare the complication rates and clinical outcomes after shoulder arthroplasty in WC patients and control non-WC patients. METHODS: An institutional shoulder arthroplasty database was queried for patients with minimum 2-year follow-up who underwent total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. WC patients were age and sex matched with non-WC patients and retrospectively evaluated for complication rates, patient-reported outcome (PRO) scores, and range of motion. RESULTS: We matched 45 WC and 45 non-WC patients by age and sex, with the WC group having a higher rate of prior surgery (82% vs 38%, P < .001). Both groups experienced significant improvements in all PROs, forward elevation, and external rotation (P < .05 for all). The WC group had inferior 2-year outcomes for all PROs and forward elevation (P ≤ .001 for all), as well as a higher reoperation rate (16% vs 2%, P = .030) and higher rate of persistent pain at final follow-up (33% vs 11%, P = .021). On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in American Shoulder and Elbow Surgeons (P < .001), functional (P < .001), and Simple Shoulder Test (P < .001) scores, as well as a higher reoperation rate (P = .015) and higher rate of persistent pain (P = .027). CONCLUSION: Although both WC and non-WC patients experienced significant clinical improvements after shoulder arthroplasty, WC patients had a higher reoperation rate, inferior PROs, and a higher rate of persistent pain.

Good functional outcomes expected after shoulder arthroplasty irrespective of body mass index.

BACKGROUND: This study evaluated how body mass index (BMI) factors into functional outcomes and complications after shoulder arthroplasty. METHODS: A retrospective analysis was performed of age-matched patients with a minimum 2-year follow-up after total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), or hemiarthroplasty (HA). Patient-reported outcome (PRO) scores, range of motion (ROM), and complications were assessed. Forty-nine patients were classified into the following groups: normal (BMI <24.9 kg/m2), overweight (BMI 25-29.9 kg/m2), class I obese (BMI 30-34.9 kg/m2), class II obese (BMI 35-39.9 kg/m2), and class III morbid obese (BMI ≥40 kg/m2). RESULTS: A total of 245 patients (134 women, 111 men; average age, 64 ± 8 years) were evaluated at an average follow-up of 48 ± 18 months. TSA was performed in 122 patients (50%), RTSA was performed in 103 (42%), and HA was performed in 20 (8%). No significant difference was found among the 5 BMI groups in arthroplasty type (P = .108) or in complications, including reoperations (P = .27). All groups had significant postoperative improvements in PROs and ROM (P < .001 for both). There were no significant differences among the BMI groups in postoperative ROM or PROs. DISCUSSION: This study demonstrates that patients undergoing TSA, RTSA, and HA can expect good functional outcomes, with improvements in pain, function and outcome scores, irrespective of BMI.

Single-Incision Anatomic Repair Technique for Distal Biceps Tendon Rupture Using Tunneling Device.

Distal biceps tendon ruptures are uncommon and generally occur in men aged 30 to 50 years in their dominant arm as a result of a strong eccentric load. Numerous surgical exposures and methods of fixation exist for repair of a ruptured distal biceps tendon. The goal of surgical management is to restore the anatomic footprint of the biceps tendon on the radial tuberosity to maximize flexion strength, supination strength, and muscle endurance. When compared with 2-incision repair techniques, single-incision repairs historically may not have restored the anatomic footprint of the distal biceps. Single-incision repair with the ArthroTunneler is a safe and effective technique that provides the anatomic restoration of a 2-incision approach with the decreased complication profile of a single-incision approach and does not require suture anchors, buttons, screws, or other implants.

Biomechanical evaluation of distal biceps tendon repair using tension slide technique and knotless fixation technique.

BACKGROUND: Acute distal biceps tendon ruptures are uncommon injuries that often affect young active males, typically resulting from an eccentric load on their dominant extremity. The purpose of this study was to compare pullout strength and tendon gapping in the tension slide technique (TST) versus a knotless fixation technique (KFT). METHODS: Two sets of experiments were performed using cadaveric elbow specimens. In the first experiment, eight elbows from different cadavers were tested to compare TST with a standard locking whipstitch with KFT, four elbows in each group, using a standard locking whipstitch. In the second experiment, 12 elbows were used to study the differences between TST with a standard locking whipstitch with KFT using suture tape reinforced whipstitch (RKFT), using the TST data from the first and second experiment. Each experiment evaluated gapping after cyclic loading and the second experiment also tested the construct to load to failure. RESULTS: Gapping for KFT with a standard locking whipstitch was 10.64 mm versus 2.69 mm for the TST after 1000 cycles (P = 0.016). A reinforced whipstitch significantly improved the failure to gap on the KFT with no significant difference in gapping when compared to TST after 3000 cycles (P = 0.36). The resultant gapping for TST and KST was 2.08 mm and 2.99 mm (P = 0.91), respectively. Load to failure for TST and KFT were 282 Nm and 328 Nm (P = 0.20), respectively. CONCLUSION: Bone-tendon gap resistance of a KFT repair of a torn distal biceps tendon is limited by suture technique. Using a tape reinforced locking whipstitch, the repair is as strong as TST repair. LEVELS OF EVIDENCE: Basic Science.

Humeral head sizing using extra-articular landmarks on conventional radiographs.

PURPOSE: Proper humeral head (HH) sizing is critical to success in anatomic shoulder replacement for management of glenohumeral arthritis. In this study, we evaluate the accuracy and reliability of using non-articular landmarks on conventional radiographs for HH templating. METHODS: Anatomic HH replacement was performed on five non-arthritic shoulders, from fresh adult cadavers. Pre-operative and post-operative radiographs and 3-D CT scans were obtained. Humeral head size was determined using the articular surface and three extra-articular landmarks (inner aspect of the lateral cortex, the medial footprint of the rotator cuff, and the medial calcar). Two independent observers performed each measurement twice to evaluate reliability. The accuracy was assessed by subtracting the mean values from both the 3D-CT and the implanted HH size measurements. RESULTS: Intraclass correlation coefficient for Observer 1 and 2 for the three-point method showed excellent test-retest reliability 0.996 (95% CI 0.994-0.998) and 0.997 (95% CI 0.995-0.998), respectively. Inter-observer ICC for the three-point method was 0.996 (95% CI 0.994-0.997) showing high level of precision. The three-point method was overestimating the size of the HH (to 3D-CT) with 0.46 ± 0.61 mm on average. The three-point method predicted the size of the HH within 1 mm of the implanted head size showing very high accuracy. The center of rotation (COR) for the three-point method was within 1.34 mm of the (COR) of the articular surface. CONCLUSION: The three-point measuring technique using conventional radiographs may be useful to predict the HH size using extra-articular landmarks within a small margin of error. This method is simple, cost effective and has high level of precision. LEVEL OF EVIDENCE: Basic Science Study; Anatomic and Imaging Study.

Arthroscopic Intramuscular Side-to-Side Repair of an Isolated Infraspinatus Tear.

Intramuscular, full-thickness rotator cuff tears are uncommon and present a challenging clinical scenario for repair because traditional suture anchor or transosseous repair techniques are less feasible. The goal of repair is to achieve a tension-free reduction of both ends of the muscle to allow for adequate healing over time. Intramuscular tears of the infraspinatus specifically have rarely been reported. The clinical presentation of these patients can be challenging to interpret, and other causes of rotator cuff dysfunction, including compression to the suprascapular nerve, must be ruled out. In this Technical Note, we describe our technique for arthroscopic side-to-side suture repair of an isolated intramuscular infraspinatus tear.

Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly.

PURPOSE: The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures. METHODS: Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences. RESULTS: Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11 years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon's decision. CONCLUSIONS: There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions. LEVEL OF EVIDENCE: Level III - Case controlled study.

Glenoid version and size: does gender, ethnicity, or body size play a role?

INTRODUCTION: Variations in glenoid morphology among patients of different gender, body habitus, and ethnicity have been of interest for surgeons. Understanding these anatomical variations is a critical step in restoring normal glenohumeral structure during shoulder reconstruction surgery. METHODS: Retrospective review of 108 patient shoulder CT scans was performed and glenoid version, AP diameter and height were measured. Statistical multiple regression models were used to investigate the ability of gender and ethnicity to predict glenoid AP diameter, height, and version independently of patient weight and height. RESULTS: The mean glenoid AP diameter was 24.7 ± 3.5, the mean glenoid height was 31.7 ± 3.7, and the mean glenoid version was 0.05 ± 9.05. According to our regression models, males would be expected to exhibit 8.4° more glenoid retroversion than females (p = 0.003) and have 2.9 mm larger glenoid height compared to females (p = 0.002). The predicted male glenoid AP diameter was 3.4 mm higher than that in females (p < 0.001). Hispanics demonstrated 6.4° more glenoid anteversion compared to African-Americans (p = 0.04). Asians exhibited 4.1 mm smaller glenoid AP diameters than African-Americans (p = 0.002). An increase of 25 kg in patient weight resulted in 1 mm increase in AP diameter (p = 0.01). CONCLUSIONS: Gender is the strongest independent predictor of glenoid size and version. Males exhibited a larger size and more retroverted glenoid. Patient height was found to be predictive of glenoid size only in patients of the same gender. Although variations in glenoid size and version are observed among ethnicities, larger sample size ethnic groups will be necessary to explore the precise relations. Surgeons should consider gender and ethnic variations in the pre-operative planning and surgical restoration of the native glenohumeral relationship. LEVEL OF EVIDENCE: Anatomic Study.

Technical Errors May Affect Accuracy of Torque Limiter in Locking Plate Osteosynthesis.

In locking plate osteosynthesis, proper surgical technique is crucial in reducing potential pitfalls, and use of a torque limiter makes it possible to control insertion torque. We conducted a study of the ways in which different techniques can alter the accuracy of torque limiters. We tested 22 torque limiters (1.5 Nm) for accuracy using hand and power tools under different rotational scenarios: hand power at low and high velocity and drill power at low and high velocity. We recorded the maximum torque reached after each torque-limiting event. Use of torque limiters under hand power at low velocity and high velocity resulted in significantly (P < .0001) different mean (SD) measurements: 1.49 (0.15) Nm and 3.73 (0.79) Nm. Use under drill power at controlled low velocity and at high velocity also resulted in significantly (P < .0001) different mean (SD) measurements: 1.47 (0.14) Nm and 5.37 (0.90) Nm. Maximum single measurement obtained was 9.0 Nm using drill power at high velocity. Locking screw insertion with improper technique may result in higher than expected torque and subsequent complications. For torque limiters, the most reliable technique involves hand power at slow velocity or drill power with careful control of insertion speed until 1 torque-limiting event occurs.

Scapular Winging: Evaluation and Treatment: AAOS Exhibit Selection.

Scapular winging is a rare, underreported, and debilitating disorder that produces abnormal scapulothoracic kinematics, which can lead to shoulder weakness, decreased range of motion, and substantial pain. Although there are numerous underlying etiologies, injuries to the long thoracic nerve or spinal accessory nerve are the most common, with resultant neuromuscular imbalance in the scapulothoracic stabilizing muscles. Early diagnosis followed by initiation of a treatment algorithm is important for successful outcomes. Most cases resolve with nonsurgical management. However, in patients with persistent symptoms despite nonsurgical management, appropriate dynamic muscle transfers can effectively treat the scapular winging, with good clinical outcomes.

When Is It Safe to Return to Driving After Spinal Surgery?

Study Design Prospective study. Objective Surgeons' recommendations for a safe return to driving following cervical and lumbar surgery vary and are based on empirical data. Driver reaction time (DRT) is an objective measure of the ability to drive safely. There are limited data about the effect of cervical and lumbar surgery on DRT. The purpose of our study was to use the DRT to determine when the patients undergoing a spinal surgery may safely return to driving. Methods We tested 37 patients' DRT using computer software. Twenty-three patients (mean 50.5 ± 17.7 years) received lumbar surgery, and 14 patients had cervical surgery (mean 56.7 ± 10.9 years). Patients were compared with 14 healthy male controls (mean 32 ± 5.19 years). The patients having cervical surgery were subdivided into the anterior versus posterior approach and myelopathic versus nonmyelopathic groups. Patients having lumbar spinal surgery were subdivided by decompression versus fusion with or without decompression and single-level versus multilevel surgery. The patients were tested preoperatively and at 2 to 3, 6, and 12 weeks following the surgery. The use of opioids was noted. Results Overall, the patients having cervical and lumbar surgery showed no significant differences between pre- and postoperative DRT (cervical p = 0.49, lumbar p = 0.196). Only the patients having single-level procedures had a significant improvement from a preoperative DRT of 0.951 seconds (standard deviation 0.255) to 0.794 seconds (standard deviation 0.152) at 2 to 3 weeks (p = 0.012). None of the other subgroups had a difference in the DRT. Conclusions Based on these findings, it may be acceptable to allow patients having a single-level lumbar fusion who are not taking opioids to return to driving as early as 2 weeks following the spinal surgery.

National trends and perioperative outcomes in primary and revision total shoulder arthroplasty: Trends in total shoulder arthroplasty.

INTRODUCTION: Total shoulder arthroplasty (TSA) is a highly successful procedure for management of glenohumeral arthritis, fractures and rotator cuff tears. The purpose of this study was to evaluate patient demographics, perioperative outcomes and assess recent national trends in both primary and revision TSA. METHODS: The National Hospital Discharge Survey database was searched for patients admitted to US hospitals for primary and revision TSA from 2001 to 2010. RESULTS: A total of 1,297 patients who underwent primary TSA and 184 patients who underwent revision TSA were identified. The rates of primary TSA (r = 0.88) and revision TSA (r = 0.85) both demonstrated a strong positive correlation with time. The mean patient age of the primary group was significantly higher than the revision group. Gender was not significantly different between the groups. There was no significant difference in the racial make-up between the revision and primary groups. African Americans accounted for 3.3 % of primaries versus 4.3 % of revisions (p = 0.615). Revision TSA patients had a significantly longer average LOS (3.06 days vs 2.46 days, p < 0.01), more medical comorbidities (6.0 vs 5.1 comorbidities, p < 0.01) and a higher rate of developing a myocardial infarction (2.2 % versus 0 %, p < 0.01) than the primary TSA group. CONCLUSIONS: This study demonstrates that the rate of TSA is rapidly increasing in the US, with over a four-fold increase in revisions and five-fold increase in primaries over the ten years studied.

Trends in the surgical treatment of lumbar spine disease in the United States.

BACKGROUND CONTEXT: There is a lack of agreement among spine surgeons as to the best surgical treatment modality for many degenerative lumbar diseases. Although there are many studies examining trends in spinal surgery, specific studies reporting the variations in surgical treatment in the United States for these diseases are lacking. PURPOSE: The aim of this study was to analyze trends in lumbar spinal fusion methods for common lumbar pathologies in the United States. STUDY DESIGN/SETTING: National insurance database review: 2004-2009. PATIENT SAMPLE: Data is taken from United Healthcare and represents more than 25 million patients. OUTCOME MEASURES: No outcomes were measured in this study. METHODS: Using a private insurance database, we identified patients who underwent one of five types of instrumented single-level lumbar spinal fusion for the 10 most common primary diagnoses. Surgery rates were reviewed from 2004 to 2009 and were stratified according to patient age, patient gender, and region in the United States. Poisson regression analysis was performed to determine regional and demographic differences in treatment modality. The authors received no funds in support of this work. RESULTS: A total of 23,986 patients met our search criteria. Of the five fusion types, posterior lumbar interbody fusion (PLIF) with posterolateral fusion (PLF) was the most common (45%), followed by PLF (19%), anterior lumbar interbody fusion (ALIF, 16%), PLIF (10%), and ALIF with PLF (9%). There was a significant increase in PLIF with PLF (p<.0001), PLIF (p<.0001), PLF (p=.012), ALIF (p<.0001), and ALIF with PLF (p<.0001) from 2004 to 2009. After controlling for gender, there were significant differences between regions for all fusion types (p<.0001). The likelihood of a posterior fusion increased with age. Anterior fusions were more common in the 30- to 49-year-old age range than in patents older than 50. For patients in age groups older than 30, there was an increased number who underwent a circumferential fusion or an ALIF (p<.022). Fusion types were significantly different between genders (p<.026). Both genders had an overall increase in the number of fusions (p<.001) over the time period studied. CONCLUSIONS: There are large differences in the United States for surgical treatment methods for lumbar spine pathology. These differences are likely multifactorial, with both patient and surgeon traits playing a role. Illustrating these differences will hopefully lead to outcomes research to determine the indications, efficacy, and appropriateness of these surgical methods, an important step on the path toward standardization of care.

Distribution of high-conductance calcium-activated potassium channels in rat vestibular epithelia.

Voltage- and calcium-activated potassium channels (BK) are important regulators of neuronal excitability. BK channels seem to be crucial for frequency tuning in nonmammalian vestibular and auditory hair cells. However, there are a paucity of data concerning BK expression in mammalian vestibular hair cells. We therefore investigated the localization of BK channels in mammalian vestibular hair cells, specifically in rat vestibular neuroepithelia. We find that only a subset of hair cells in the utricle and the crista ampullaris express BK channels. BK-positive hair cells are located mainly in the medial striolar region of the utricle, where they constitute at most 12% of hair cells, and in the central zone of the horizontal crista. A majority of BK-positive hair cells are encapsulated by a calretinin-positive calyx defining them as type I cells. The remainder are either type I cells encapsulated by a calretinin-negative calyx or type II hair cells. Surprisingly, the number of BK-positive hair cells in the utricle peaks in juvenile rats and declines in early adulthood. BK channels were not found in vestibular afferent dendrites or somata. Our data indicate that BK channel expression in the mammalian vestibular system differs from the expression pattern in the mammalian auditory and the nonmammalian vestibular system. The molecular diversity of vestibular hair cells indicates a functional diversity that has not yet been fully characterized. The predominance of BK-positive hair cells within the medial striola of juvenile animals suggests that they contribute to a scheme of highly lateralized coding of linear head movements during late development.